at least with those paper presentations to open up for any questions in the audience. I didn't see any on the app yet, but anybody have any questions about that? You know, one question I have, Dr. Butler, so when you're looking at the difference between insertional and non-insertional, was there any issue that you all found that I didn't see there as far as if there was calcific change at the insertion with the tendon compared to non-calcific? Because I've certainly found myself that once they get that significant calcific change that whether it's 10x, whether it's ESWT, that those are the ones that I end up needing to do something more for in the long term, and I was just curious as to your perspective on that. So in total, about 80% of the insertional had some degree of calcific tendinosis. All of the patients with a high glands had calcific tendinosis, and the vast majority of them required surgery, but for the non-insertional, there was one patient who had calcific tendinosis at the insertion but had no pain there at all. Very good. And Dr. Lal, you know, so in thinking about that, one of the biggest things I struggle with is at what point, you know, was, if it's coming to me as a second opinion, as far as, you know, some type of microfracture, debridement, did the initial procedure fail because it was inadequately debrided and you didn't get through a sclerotic area in the lesion? You know, in your all's perspective, what's the reason to, other than size or significant cystic change, to jump to an OCA compared to doing a revision, maybe more thorough microfracture slash debridement? You know, I think most of the considerations are based on size. I think, you know, if you can, probably the best way to give a good outcome is if you can use autograft, those dowels, like if you take it from a non-weight-bearing area, but, you know, the mean size in our group was 41%, so I really don't think, I think if you can try to avoid doing this based on size, you should, but, you know, when you get that significant subchondral change where it dips way down into the talus or you get something that crosses over the midline, it's really hard to recreate that with a snowman, you know? And I also saw that, at least as far as fixation, because that's the other consideration here, it was kind of a split between, you know, bioabsorbable pins or screws versus metal. Did you all see any difference as far as survivorship, because it was a pretty high survivorship already, but did you find that the bioabsorbables were less likely to survive compared to the metal or vice versa? What'd you see there? So, you know, this is a glaring limitation of the study is that there was no, we didn't look at survivorship based on fixation or did we look at lesion location, and I think that could be a future direction, and nor did we look at any radiographs. I mean, this is a clinical only study. I can tell you that just from experience, using those bioabsorbable pins in something as dense as the talus is fraught with danger, and it's a much more controlled experience using a fully threaded screw, compression screw, and it's just a much more controlled experience. You can drill, get the right depth. Yeah, no, I agree. I mean, I found the same way even in the knee, but that's why I was curious when I saw that, that, you know, I mean, I think at least 40% of them were maybe fixed with bioabsorbable, so I was curious. Any other thoughts from the audience? Hi, Raheel Shourie from the UK. Congratulations to the speakers. Excellent presentations. My question is to Dr. Dalal. Your results are fantastic, far superior to most published literature, which is about 50 to 60% at best. Couple of questions. Firstly, you alluded to the size of the lesion. Did you look at survivorship based on size? Was there some element of linear correlation there? And secondly, how many of these defects were contained or uncontained? Final question, what are you doing different or what's your team doing different that your results seem to be, you know, pretty spectacular? So you know this, like I mentioned, one of the limitations is that we did not look at survivorship based on size. These are not my personal cases, they're Dr. Bugbee's and he is probably more gifted than most and does a lot of these surgeries. I think, I think the thing is the more you do, the better you get. He also has like a very motivated patient population that seeks him out from across the country. I mean, people fly in, as soon as their graft is available, people will drop everything and fly in from Minnesota to have him do it. So I think you definitely get like a selection bias there. You're selecting for the most motivated, highly resourced, competitive patients and I'm sure that plays a role. Thank you. Just a quick follow up. Did you have a mean size to your cohort? 36. Jason. Yes, sir. Amal Saxena from Palo Alto, California. So not all extracorporeal shockwave is created equal. What type of device did you use and did you use more than one? So we used a dual led device and they're all focused shockwave, they weren't radial. Okay. Yeah, I've published and Adam 1040 has published, using radial and focus combined actually improves your outcomes. With radial only, we got about 75%. With combined, we get about 89% of people better. Was that with insertional and non-insertional or primarily non-insertional? It's with both. But I agree, if the shape of the calcaneus is severely spiked, sometimes I don't even offer it. If they have a fractured insertional calcification, I usually tend not to offer it either. Just as a follow-up comment on that, we use a lot of shockwave in our center and we found what you found. I mean, if you have a lot of calcifications distally, you can sometimes exacerbate their symptoms with shockwave in our experience. And that has actually been defined in the shoulder as well with calcific tendinosis. They either get really much better or they actually get much worse. They rarely fall in the middle. And so I think it's just something to be aware of based on the device that you use. All right. Well, very good. We want to certainly thank our paper presenters as well. And then we'll kind of move on to the next section here. Thank you very much.

tendon injuries

treatments

calcific changes

insertional tendinosis

non-insertional tendinosis